Founded in 1867...A Mutual Company...P.O. Xxx 00000, Xxxxxxxxxx,
Xxxx 00000
ANNUITANT: Xxxx Xxx
OWNER: Xxxx Xxx
CONTRACT NUMBER: 01234567
CONTRACT DATE: April 05, 2001
WE PROMISE to pay the benefits of this contract in accordance
with its terms.
LOOK AT THE APPLICATION FORMS. This contract is issued based on
payment of the initial premium and the answers in the application
(see copy attached). If all answers are not true and complete,
this contract may be affected.
PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract
between you and Union Central.
20 DAY RIGHT TO EXAMINE THE CONTRACT. It is important to Union
Central that you are satisfied with this contract. You have 20
days after you receive it to review the policy. If you are not
satisfied, you may send it back to us or give it to our agent.
In such case, this contract will be void from the beginning. We
will refund, within 7 days after this contract is returned, any
premiums paid.
ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS
CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE
ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNTS.
Signed for the Company at Cincinnati, Ohio
/s/ Xxxxx X. Xxxxxxxxxx /s/ Xxxx X. Xxxxxx
Secretary President
Flexible Premium Deferred Variable Annuity
Participating
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Licensed Resident Agent
UC 8135-1 5/01
INTRODUCTION
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This is a flexible premium deferred variable annuity. This
annuity contract provides that both the accumulation value and
annuity payments may be either fixed or variable, or a
combination of fixed and variable.
You determine the investment allocation for this annuity. You
may allocate your premiums to either the guaranteed account or
the variable account, or a combination of these accounts. If you
select the guaranteed account, then your accumulation value and
annuity payments will be fixed and guaranteed. If you select the
variable account, your accumulation value and annuity payments
will vary with the investment performance of the separate
account's subaccounts. If you select both the guaranteed and
variable accounts, then your values and payments will be fixed in
part, and variable in part.
If you select the variable account, then you must allocate
premiums among one or more subdivisions of the variable account.
These subdivisions are identified in the contract application
and on the schedule page.
CONTRACT INDEX
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Page
Definitions. . . . . . . . . . . . . . . . . . . . . . . . 4
Ownership. . . . . . . . . . . . . . . . . . . . . . . . . 6
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 6
Premiums . . . . . . . . . . . . . . . . . . . . . . . . . 9
Guaranteed Account Provisions. . . . . . . . . . . . . . .11
Transfers. . . . . . . . . . . . . . . . . . . . . . . . .12
Surrender Provisions . . . . . . . . . . . . . . . . . . .12
Charges and Deductions . . . . . . . . . . . . . . . . . .13
General Provisions . . . . . . . . . . . . . . . . . . . .14
Payment of Contract Benefits . . . . . . . . . . . . . . .15
Schedule Page
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Initial Allocation of Net Premiums: Money Source
Separate Account: Carillon Account
SUBDIVISIONS OF THE VARIABLE ACCOUNT:
[AIM VI CAP APPRECIATION 0]%
[AIM VI GROWTH 0]
[XXXXX AMERICAN LEVERAGED ALLCAP 0]
[XXXXX AMERICAN MIDCAP GROWTH 0]
[AM CENTURY VP GROWTH & IN 0]
[AM CENTURY VP VALUE 0]
[MFS VIT EMERGING GROWTH 0]
[MFS VIT INVESTORS TRUST 0]
[MFS VIT HIGH INCOME 0]
[MFS VIT NEW DISCOVERY 0]
[MFS VIT TOTAL RETURN 0]
[XXXXXXXXX XXXXXX AMT GUARD 0]
[XXXXXXXXXXX GLOBAL SEC/VA 0]
[XXXXXXXXXXX MAIN ST/VA 0]
[XXXXXXX VSI CAP GROWTH 0]
[XXXXXXX VSI INTL 0]
[XXXXXXX VSI MONEY MARKET 0]
[XXXXXXXX SMALLCAP VALUE CLASS 2 0]
[XXXXXXXX COMM & INFO CLASS 2 0]
[SUMMIT BALANCED INDEX 0]
[SUMMIT BOND 25]
[SUMMIT NASDAQ 100 INDEX 0]
[SUMMIT XXXXXXX 2000 0]
[SUMMIT S&P MID CAP 400 0]
[SUMMIT S&P 500 INDEX 0]
[SUMMIT ZENITH 25]
[FTVIP XXXXXXXXX INTL CLASS 2 0]
GUARANTEED ACCOUNT: [50]
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TOTAL: 100%
Transfer Charge:
Current: [$10]
Maximum: $100
Mortality and Expense Charge:
Current: [1.20%]
Maximum: 2.00%
Administration Fee:
Current: [0.25%]
Maximum: 0.25%
Guaranteed Interest Rate: 3.00%
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Annuitant: Xxxx Xxx Contract Number: 01234567
Owner: Xxxx Xxx Maturity Date: February 01, 2058
Joint Owner: N/A Contract Date: April 05, 2001
UC 8135-1 - 3 -
DEFINITIONS
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ACCUMULATION Means the period before the maturity date
PERIOD and during the lifetime of the annuitant.
ACCUMULATION Means a unit of measure that is used to
UNIT calculate the value of your interest in the
separate account (SA) before the maturity
date.
ACCUMULATION Means the sum of the values of the guaranteed
VALUE account and the variable account credited to
this contract.
ANNUITANT Means the person(s) whose life is used to
determine the duration of any annuity payments
involving life contingencies. The annuitant
is named in the application and on the schedule
page.
ANNUITY UNIT Means a unit of measure that is used to
calculate variable annuity payments.
BENEFICIARY Means the person(s) designated by you to
receive the death benefits from this contract
upon your death.
CALCULATION DATE Means a date not more than 10 business days
prior to the maturity date.
CONTRACT YEAR Means a period of 12 consecutive months
beginning on the contract date or any
anniversary thereafter. The contract date
is shown on the schedule page.
DUE PROOF Means one of the following:
OF DEATH 1. A certified copy of a death certificate;
2. A certified copy of a decree of a court of
competent jurisdiction as to the finding of
death;
3. A written statement by a medical doctor who
attended the deceased; and
4. Any other proof satisfactory to us.
FIXED ANNUITY Means an annuity with payments fixed throughout
the annuity payment period.
GUARANTEED Means this contract's value which is held by
ACCOUNT The Union Central Life Insurance Company other
than those in its separate accounts (SA).
HOME OFFICE Means the home office of The Union Central
Life Insurance Company which is:
0000 Xxxxxxxx Xxxx (X.X. Xxx 00000),
Xxxxxxxxxx, Xxxx 00000.
MATURITY DATE Means the date on which annuity payments will
begin. This date shall be the annuitant's 95th
birthday unless an earlier date is chosen by
you.
NOTICE Means information we have received at our
home office which is written, is signed by
you, and is acceptable to us.
PORTFOLIO OR Means a separate portfolio of one of the
FUND PORTFOLIO mutual funds in which separate account (SA)
invests through its subaccounts, or its
successors and assigns.
SCHEDULE PAGE Means the contract schedule page, or the
supplemental contract schedule page most
recently sent to you by us.
SEPARATE ACCOUNT Means the Carillon Account of The Union
("SA") Central Life Insurance Company. The separate
account is divided into several subaccounts.
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SUBACCOUNT(S) Means one or more of the subaccounts of the
SA. Each subaccount is invested in a
different fund portfolio.
SUBDIVISION Means the portion of your variable account
which is invested in a specific subaccount.
VARIABLE ACCOUNT Means this contract's value which is
invested in one or more subaccounts of
the SA.
VARIABLE ANNUITY Means an annuity with payments which:
(1) are not predetermined or guaranteed
as to dollar amount; and (2) vary in amount
in relation to the investment experience of
one or more specified subaccounts.
WE AND YOU "We," "us," or "our" means The Union Central
Life Insurance Company. "You" or "your" means
the owner of this contract.
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OWNERSHIP
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GENERAL The owner of this contract shall be the
person so named in the application or the
latest change filed with us.
CHANGE OF Prior to the maturity date, you may assign
OWNERSHIP the ownership of this contract. Such change
must be made by written notice in a form
acceptable to us and received at our home
office.
CHANGE OF Prior to the maturity date, you may name a
ANNUITANT new annuitant. Such change must be made by
written notice in a form acceptable to us
and received at our home office.
BENEFITS
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ANNUITY BENEFITS We will pay an annuity benefit to the
annuitant, if living, on the maturity
date. Annuity benefits will begin on the
maturity date and continue while the
annuitant is living, with monthly payments
guaranteed for 10 years, unless you elect
a different annuity option at least 30 days
before the maturity date. If you die after
the annuity benefits have begun, the entire
remaining interest will continue to be
distributed to the annuitant at least as
rapidly as under the annuity option being
used as of the date of your death.
We may pay the accumulation value on the
maturity date in one lump sum if it is less
than $5,000. We may change the payment
frequency to quarterly, semiannually or
annually if the first monthly annuity
payment would be less than $50.
At least 30 days before the maturity date
you must select how the accumulation value
will be used to provide the annuity benefit.
Any election must be written in a form
satisfactory to us and received at our home
office. If you do not so select how you wish
settlement to be effected, we will provide a
fixed annuity.
If a variable annuity is used, subsequent
annuity benefit payments will vary based on
the investment experience of the subaccount(s)
used to effect the annuity. The method used
to calculate the amount of subsequent payments
is described in the Variable Annuity Payments
provision.
DEATH BENEFITS Notwithstanding any provision to the
contrary, death benefits shall always be
made in accordance with the distribution
requirements of the Internal Revenue Code.
If the death benefit is paid before the
maturity date, the death benefit will be
the greater of : (a) the accumulation value
on the date that due proof of death is
received; or (b) the sum of all premiums
paid, less any amounts deducted in
connection with partial surrenders.
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Death of Owner. If you are an owner and if
you die before the maturity date, the
following will apply:
1. If your spouse is not the beneficiary, the
death benefit will be paid to the named
beneficiary:
a. upon written request it may be paid
under any option listed in the Payment
of Contract Benefits section of this
contract over a period not exceeding
the beneficiary's life expectancy. If
the death benefit is paid in
installments, the first installment
payment must be made no later than one
year after the date of your death; or
b. in a single sum. The beneficiary has
the option to elect to receive the single
sum any time within five years after the
date of your death.
2. If your spouse is the beneficiary, your
spouse may elect, by a written request to us,
one of the following options:
a. to continue this contract as the owner;
or
b. to receive the death benefit under any
option listed in the Payment of Contract
Benefits section of this contract over a
period not exceeding the beneficiary's
life expectancy. If the death benefit is
paid in installments, the first
installment payment must be made no later
than one year after the date of your
death; or
c. to receive the death benefit in a single
sum. Your spouse may elect to receive the
single sum any time within five years
after the date of your death.
If none of these options is elected by your
spouse within 45 days after we receive due
proof of death, option a. above shall apply.
3. If no beneficiary is living or if no
beneficiary has been named, at the date of
your death, the death benefit will be paid
in a single sum to the executor or
administrator of your estate within five
years after the date of your death.
Joint Owners. If this contract is owned
jointly, the death of the first joint owner
shall be treated as the death of the owner.
Death of Annuitant before the Maturity Date.
If you, the owner, are a different person from
the annuitant, and the annuitant dies during
your lifetime and before the maturity date,
you will be treated as the annuitant. If you
are not a natural person, and the annuitant
dies before the maturity date, we will pay the
death benefit to you in a single sum. You have
the option to elect to receive the single sum
any time within five years of the death of the
annuitant.
Death of Annuitant on or after the Maturity
Date. If the annuitant dies on or after the
maturity date, the death benefit, if any, will
depend on the annuity option in effect on the
date of the annuitant's death.
Death of Beneficiary. Unless otherwise
provided, if any beneficiary dies before, at
the same time as, or within 30 days after your
death, that beneficiary will be treated as if
their death occurred before yours.
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UC 8135-1 -7- 5/01
PREMIUMS
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GENERAL All premiums under this contract are payable at
our home office or such other place as we may
designate.
No premium may be paid under this contract
unless it is at least $50. Premiums may be
paid at any time. The amount of the premium
may be increased or decreased any time subject
to the $50 minimum and a maximum of $10,000
per contract year. We may waive the $10,000
per year maximum, but waiver in one instance
does not constitute waiver for additional
premiums.
NET PREMIUM The net premium is the premium less any
premium tax.
ALLOCATION OF You determine the allocation of the net
NET PREMIUM premiums between the guaranteed account and
the variable account. You may allocate the
net premiums totally to the guaranteed
account, totally to the variable account
or partially to both accounts. The minimum
amount of any net premium that you can
allocate to the guaranteed account or any
subdivision of the variable account is $10.
If you allocate a part or all of your
premiums to the variable account, then you
will further allocate that portion of your
premiums among one or more subdivisions of
the variable account. To the extent that
you allocate premiums to the variable
account, your accumulation value will be
subject to the investment experience of SA.
Premiums that you allocate to the guaranteed
account will be guaranteed a minimum value.
We will credit interest to amounts allocated
to the guaranteed account at a rate of at
least the guaranteed interest rate as shown
on the schedule page, compounded annually.
We may credit a higher rate of interest to
such amounts, but we are not required to do so.
When we receive the premiums, the net premiums
will be allocated in accordance with the net
premium allocation percentages shown in the
application or as of the most recent change
of allocation received from you. No allocation
will be made prior to the contract date. You
may change the allocation of subsequent
premiums at any time, without charge, by
giving us written notice.
VARIABLE ACCOUNT PROVISIONS
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SEPARATE ACCOUNT The separate account is shown on the schedule
page. It is a unit investment trust registered
with the Securities and Exchange Commission
under the Investment Company Act of 1940. It
is established under the laws of Ohio. The
assets in the separate account are kept
separate from our general assets and assets
of other separate accounts.
SUBACCOUNTS The separate account is divided into
subaccounts, each of which invests in a
different portfolio.
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UC 8135-1 -8- 5/01
CREDITING OF We will credit net premiums allocated to the
ACCUMULATION variable account in the form of variable
UNITS accumulation units. The number of variable
accumulation units to be credited to this
contract for each subdivision of the variable
account will be determined by dividing the net
premium allocated to each subdivision of the
variable account by the accumulation unit
value for the corresponding subaccount as of
the end of the valuation period during which
the premium is received. In the case of the
initial premium, accumulation units will be
credited on the later of these dates:
1. the contract date; or
2. the date we receive the premium.
At the end of the Right to Examine period,
those units will be allocated to the
subaccounts chosen on your application.
Accumulation units are credited when amounts
are transferred into a subaccount.
Accumulation units are deducted when the
charges and deductions are assessed or when
amounts are partially surrendered or
transferred, including transfer charges, out
of a subaccount.
VARIABLE ACCOUNT At any time prior to the maturity date, the
variable account of this contract equals the
sum for all subdivisions of the variable
account of (1) times (2) where:
1. equals the number of accumulation units
credited to a subdivision of the variable
account; and
2. equals the value of the appropriate
accumulation unit.
VALUATION DATE A valuation date is any date on which the
AND VALUATION New York Stock Exchange is open for trading
PERIOD and we are open for business. The assets of
each subaccount will be valued on each
valuation date. A valuation period is a
period beginning with the close of business
on a valuation date and ending at the close
of business for the next valuation date.
ACCUMULATION The value of a variable accumulation unit for
UNIT each subaccount was arbitrarily set at $10
when funds were first credited to the
respective subaccount. The variable
accumulation unit value for any subsequent
valuation period is determined by multiplying
the variable accumulation unit value for the
immediately preceding valuation period by the
"net investment factor" for the valuation
period for which the value is being determined.
The value of a variable accumulation unit may
increase or decrease from one valuation period
to the next.
NET INVESTMENT The net investment factor is an index that
FACTOR measures the investment performance of a
subaccount from one valuation period to the
next. The net investment factor for each
subaccount for any valuation period is
determined by dividing (1) by (2) and
subtracting (3) from the result, where:
1. is the net result of:
a. the net asset value per share of a
portfolio share held in the subaccount
determined as of the end of the current
valuation period, plus
b. the per share amount of any dividend or
capital gain distributions made by the
portfolio on shares held in the
subaccount if the "exdividend" date
occurs during the current valuation
period, plus or minus
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c. a per share charge or credit for any
taxes incurred by or reserved for in the
subaccount, which is determined by us to
have resulted from the maintenance of
the subaccount; and
2. is the net result of:
a. the net asset value per share of a
portfolio share held in the subaccount
determined as of the end of the
immediately preceding valuation period
(adjusted for an "exdividend"), plus or
minus
b. the per share charge or credit for any
taxes reserved for the immediately
preceding valuation period; and
3. is a factor representing the charges
deducted from the subaccounts on a daily
basis for administrative expenses and
mortality and expense risks. Such factor
is equal on an annual basis to the amount
shown on the schedule page.
VARIABLE ANNUITY The amount of the first variable annuity
PAYMENT payment is determined by applying the
variable account accumulation value of
your contract, measured as of the
calculation date (minus any applicable
premium taxes), to the appropriate Option
Table contained in this contract. This is
done separately for each subdivision of
the variable account. We will determine
subsequent payments by dividing the first
payment derived from each subdivision of the
variable account by the annuity unit value
determined as of the calculation date. This
number of annuity units is then multiplied
by the annuity unit value for each subsequent
determination date which is a uniformly
applied date not more than 10 business days
before payment is due.
ANNUITY UNIT The value of an annuity unit for each
VALUE subaccount was arbitrarily set at $10 when
funds were first credited to the respective
subaccount. Subsequently, the value of an
annuity unit in each subaccount for any
valuation period is determined as follows:
(1) the net investment factor for each
subaccount for the valuation period for
which the annuity unit value is being
calculated is multiplied by the value of
the annuity unit on the preceding valuation
date; and
(2) the result is adjusted to compensate for
the interest rate assumed in the Option
Tables used to determine the first
variable annuity payment.
The dollar value of annuity units may change
from one valuation period to the next.
ADDITION, We reserve the right, subject to compliance
DELETION, OR with applicable law, to make additions to,
SUBSTITUTION OF deletions from, or substitution for the
INVESTMENTS portfolio shares that are held by the
separate account or that the separate
account may purchase. We reserve the right
to eliminate the shares of any of the
eligible portfolios and to substitute
shares of another portfolio, or of another
open-end, registered investment company,
if the shares of an eligible portfolio are
no longer available for investment, or if
in our judgment further investment in any
eligible portfolio should become
inappropriate in view of the purposes of
the separate account. We will not
substitute any shares attributable to
your interest in a subaccount without
notice to you and prior approval of the
Securities and Exchange Commission, to
the extent required by the Investment
Company Act of 1940. Nothing contained
herein shall prevent the separate account
from purchasing other securities for other
series or classes of policies, or from
effecting a conversion between series or
classes of policies on the basis of requests
made by owners.
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We reserve the right to establish additional
subaccounts, each of which would invest in a
new portfolio, or in shares of another open-end
investment company. We also reserve the right
to eliminate existing subaccounts.
In the event of any such substitution or
change, we may, by appropriate endorsement,
make such changes in this and other policies
as may be necessary or appropriate to reflect
such substitution or change. If deemed by us
to be in the best interest of persons having
voting rights under the policies, the separate
account may be operated as a management company
under the Investment Company Act of 1940 or it
may be deregistered under such Act in the event
such registration is no longer required.
The investment contract of the separate account
will not be changed without the approval of the
Insurance Commissioner of the State of Ohio.
If required, the approval process is on file
with the Commissioner of the state in which
this contract is issued.
GUARANTEED ACCOUNT PROVISIONS
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GUARANTEED The guaranteed account of your contract
ACCOUNT at any time equals:
1. the total of all net premiums allocated to
the guaranteed account; plus
2. the total of all amounts transferred to the
guaranteed account from the variable
account; minus
3. the total of all amounts transferred from
the guaranteed account to the variable
account (including the transfer fee); minus
4. the total of all partial surrenders from the
guaranteed account; plus
5. interest.
GUARANTEED The guaranteed interest rate used in the
ACCOUNT INTEREST calculation of the guaranteed account is found
RATE on the schedule page. Interest in excess of
the guaranteed rate may be used in the
calculation of the guaranteed account at such
increased rates and in such a manner as we may
determine.
FIXED ANNUITY We guarantee the amount of fixed annuity
PAYMENTS payments. The payment amount depends only on
the annuity option elected, the age (and
possibly sex) of the annuitant, and the amount
applied to purchase the fixed annuity, in
accordance with the Option Tables contained in
the contract.
TRANSFERS
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TRANSFERS BEFORE Before the maturity date you may transfer
MATURITY DATE amounts between the guaranteed account and
subdivisions of the variable account or
among subdivisions. Transfers from
subdivisions of the variable account will
be made based on the accumulation unit
values at the end of the valuation period
during which we receive the request for
transfer. You must transfer at least $300
or, if less, the entire amount in the
guaranteed account or a subdivision each
time you make a transfer. If after the
transfer the amount remaining in the
guaranteed account or any subdivision of
the variable account from which the transfer
is made is less than $25, then we will
transfer the entire amount instead of the
requested amount. A transfer charge as
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shown on the schedule page will be imposed for
each transfer. The charge will be deducted
from the account from which the transfer is
made.
TRANSFERS AFTER After annuity payments have been made for at
MATURITY DATE least 12 months, you may, no more than once
each 12 months, change all or part of the
investment upon which your annuity payments
are based from one subaccount to another.
After your death, the annuitant assumes this
right. To do this, we will convert the number
of annuity units being changed to the number
of annuity units of the subaccount to which
you are changing so as to result in the next
annuity payment being of the same amount that
it would have been without the change. After
that, annuity payments will reflect changes in
the values of your new annuity units. You must
give us notice at least 30 days before the due
date of the first annuity payment to which the
change will apply.
No transfers may be made with respect to fixed
annuity payments.
SURRENDER PROVISIONS
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PAYMENT OF You may totally or partially surrender the
SURRENDERS contract and receive all of the accumulation
value at any time before the earlier of the
death of the annuitant or the maturity date,
by sending us a written request. We will pay
all surrenders from the variable account
within seven days of receipt of the written
request, subject to postponement for any
period during which the New York Stock
Exchange is closed for trading (except for
normal holiday closing) or when the
Securities and Exchange Commission has
determined that a state of emergency
exists. We reserve the right to postpone
surrenders from the guaranteed account for
up to six months after we receive the
request.
PARTIAL SURRENDER If you are partially surrendering the
contract, you should specify the amounts
that should be withdrawn from the
guaranteed account or each subdivision
of the variable account. If you do not
so specify, the requested amount will be
withdrawn from the guaranteed account and
each subdivision of the variable account
in which you have an interest, in the same
proportion that your interest therein
bears to the accumulation value. You may
pre-authorize periodic surrenders by
entering into a separate agreement with
us. Under this agreement, you may
withdraw part of your accumulation value
at a regular interval chosen by you. You may
choose to withdraw a level dollar amount
or a percentage of your accumulation value.
If you choose the latter, the accumulation
value for the first year you choose to make
these withdrawals is set on the date we
approve your request. In later years, the
accumulation value is set on the first day
of the contract year. These surrenders may
be subject to the 10% federal tax on early
withdrawals.
FREQUENCY AND You may make as many partial surrenders as
AMOUNT OF you wish. Any surrender from the guaranteed
SURRENDERS account or a subdivision of the variable
account must be at least $100 or the entire
balance of the guaranteed account or
subdivision of the variable account. If,
after the surrender, the amount remaining
in the guaranteed account or a subdivision
is less than $25, then we may consider the
surrender request to be a request for
surrender of the entire amount held in the
guaranteed account or subdivision. If a
partial surrender would reduce the
accumulation value to less than $100, then
we may treat the partial surrender request
as a total surrender of the contract.
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CHARGES AND DEDUCTIONS
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MORTALITY AND To compensate us for assuming the mortality
EXPENSE RISK and expense risks, we deduct from the
CHARGE variable account a charge each valuation
period. The current charge is shown on the
schedule page as is the maximum effective
annual rate that can be charged. We will
deduct the charge from each subdivision of
the variable account in the same proportion
that the value of each subdivision bears to
the variable account.
SURRENDER CHARGE A surrender charge will never be imposed on
total or partial surrenders of this contract.
ADMINISTRATION We deduct from the variable account a charge
FEE each valuation period to partially defray the
expenses of maintaining the contract. The
current charge is shown on the schedule page
and is the maximum effective annual rate that
can be charged.
TAXES We will charge certain taxes against your
premiums, accumulation value, or annuity
payments, when incurred. These taxes include
any premium taxes or other taxes levied by
any government entity which we, in our sole
discretion, determine have resulted from:
1. the establishment or maintenance of the
variable account; or
2. from the investment experience of the
variable account; or
3. from the receipt by us of the premium; or
4. from the issuance of this contract, or
5. from the commencement or continuance of
annuity payments under this contract.
GENERAL PROVISIONS
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ENTIRE CONTRACT This contract is a legal contract that you
have entered into with us. The entire
contract consists of this contract, any
endorsements, schedule pages, amendments,
and the attached copy of the application
and supplemental applications. Any change
in the contract must be written and signed
by our President, one of our Vice Presidents,
our Secretary or Assistant Secretary. No
agent or person other than the above-named
has the authority to change or modify this
policy or waive any of its provisions. Words
that can be interpreted as singular or plural
shall mean both singular and plural.
BENEFICIARY The primary and any contingent beneficiaries
of this contract are named in the application.
If changed, the beneficiary is as shown in
the latest change. Unless the beneficiary
designation provides otherwise, any death
benefits will be divided equally among
beneficiaries of the same class. The
contingent beneficiary will receive the
death benefits if no primary beneficiary
is living at the time of the event giving
rise to the benefit payment. Prior to the
maturity date, if no beneficiary survives
you, your estate will be the beneficiary.
The interest of any beneficiary is subject
to that of any assignee.
CHANGE OF You may change the beneficiary, unless an
BENEFICIARY irrevocable designation has been made. Any
such change must be made by written notice
in a form acceptable to us and received at
our home office. If you die after the
maturity date, the annuitant may change the
beneficiary unless an irrevocable designation
has been made.
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XXXXXX XX Prior to the maturity date, you may change
MATURITY DATE the maturity date by written request at least
30 days before the previously specified
maturity date. After the election, the new
maturity date will become the maturity date.
ASSIGNMENT You may assign this contract. No assignment
will be binding on us unless it is written
in a form acceptable to us and received at
our home office. We will not be responsible
for the validity of any assignment. We will
not be liable for any payments we make or
actions we take before we receive notice of
an assignment.
CLAIMS OF Any accumulation value, before paid, under
CREDITORS this contract, will not be subject to the
claims of a beneficiary's creditors, except
as required by law.
MISSTATEMENT AND We may require proof of age, sex, or
PROOF OF AGE, survival of any person upon whose age, sex,
SEX OR SURVIVAL or survival any payments depend.
If the age or sex of the annuitant has been
misstated, the benefits will be those which
the premiums would have provided for the
correct age and sex. If we have made
incorrect annuity payments, we will adjust
future payments. The adjustments will reflect
any overpayment or underpayment.
DIVIDEND As long as this contract is in force, you will
receive any dividends declared by us. It is
anticipated that no dividends will be declared.
You have these options:
1. take the dividends in cash; or
2. use the dividends to be credited as
additional accumulation units with respect
to the variable account or added to the
guaranteed account.
You may choose either option or change options
by notice to us. If none is chosen, the second
option will be used.
REPORTS At least once a year we will send you a report
showing:
1. the accumulation unit value as of the
beginning date of the report;
2. the accumulation unit value as of the
ending date of the report;
3. the total number of accumulation units
as of the ending date of the report;
4. the value of the guaranteed account and/or
each subdivision of the variable account
on the beginning date of the report;
5. the value of the guaranteed account and/or
each subdivision of the variable account
on the ending date of the report; and
6. the gain or loss for each subdivision of
the variable account and/or the guaranteed
account.
For the column headings within the report, the
accumulation unit is referred to as "unit."
INSULATION The assets of SA are not chargeable with
liabilities arising out of any other business
we may conduct.
OWNERSHIP OF We shall have exclusive and absolute
ASSETS ownership and control of our assets,
including the assets of SA.
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MODIFICATION We may not modify this contract without
OF CONTRACT your consent except:
1. to make the contract meet the requirements
of the Investment Company Act of 1940;
2. to make the contract comply with any
changes in the Internal Revenue Code; or
3. as required by any other applicable law
in order to continue treatment of the
contract as an annuity.
INCONTESTABILITY We cannot contest this contract after it has
been in force during the lifetime of the
annuitant for a period of two years from the
date of issue.
PAYMENT OF CONTRACT BENEFITS
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GENERAL Annuity benefits under this contract are
payable in accordance with the Option Tables
given below or under such other annuity
options as we may agree to.
ALTERNATE
ANNUITY OPTIONS Instead of an annuity in accordance with the
Option Tables given below, you may choose an
alternate type of fixed annuity payment. Such
alternate annuity option shall be based on
rates at least as favorable as those for fixed
dollar single premium immediate annuities being
issued by us on the maturity date. They may
only be elected within 30 days before that
date.
DESCRIPTION OF Option 1: Life Annuity
ANNUITY OPTIONS
(a) Nonrefund. We will make payments during
the lifetime of the annuitant. No
payments are due after the death of the
annuitant.
(b) 5-Years Certain. We will make payments
for 5 years and after that during the
lifetime of the annuitant. No payments
are due after the death of the annuitant
or, if later, the end of the 5-year period
certain.
(c) 10-Years Certain. We will make payments
for 10 years and after that during the
lifetime of the annuitant. No payments
are due after the death of the annuitant
or, if later, the end of the 10-year
period certain.
(d) Installment Refund. We will make payments
for a period certain and after that during
the lifetime of the annuitant. No payments
are due after the death of the annuitant
or, if later, the end of the period
certain. The number of period certain
payments is equal to the amount applied
under this Installment Refund Option
divided by the amount of the first annuity
payment; provided, however, that the
amount of the final period certain payment
shall be multiplied by that part of the
preceding quotient which is not an integer.
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Option 2: Joint and Survivor Life Annuity
(a) Joint and Survivor Nonrefund. We will
make payments during the joint lifetime
of the annuitant and contingent annuitant.
Payments will then continue during the
remaining lifetime of the survivor of
them. No payments are due after the
death of the last survivor of the
annuitant and contingent annuitant.
(b) Joint and Survivor with 10-Years Certain.
We will make payments for 10 years and
after that during the joint lifetime of
the annuitant and contingent annuitant.
Payments will then continue during the
remaining lifetime of the survivor of
them. No payments are due after the
death of the survivor of the annuitant
and contingent annuitant or, if later,
the end of the 10-year period certain.
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Flexible Premium Deferred Variable Annuity
Participating
UC 8135-1
